Viva · IR system
Emergency IR Viva Questions
Oral-exam style questions and answers on emergency ir for MD, DNB and super-specialty practical examinations. Each answer links back to the playbook or Library entry it was written from.
- Which trauma patient is suitable for solid-organ angioembolization?
- The ideal patient is hemodynamically stable or stabilized, has no competing indication for immediate laparotomy and has CT or angiographic evidence of arterial bleeding, pseudoaneurysm or AVF. Selected transient responders may undergo embolization only where continuous resuscitation, surgery and rapid escalation are immediately available.
- When should a stable splenic injury be embolized?
- SAE is first-line for an adult with arterial blush, irrespective of grade. WSES also suggests angiography and possible SAE for stable AAST grade IV–V injuries even without blush, while routine embolization of grade III injury without vascular abnormality remains individualized.
- How do proximal and distal splenic embolization differ?
- Proximal embolization lowers splenic perfusion pressure while collateral pathways maintain viability and is favored for multifocal or high-grade injury. Distal embolization treats a focal branch injury but causes segmental infarction and has more minor infarction-related complications.
- Where should proximal splenic artery embolization be performed?
- The usual target is the main splenic artery after the dorsal pancreatic origin and before the pancreatica magna origin. This preserves pancreatic and collateral splenic pathways while reducing splenic arterial pressure.
- Why must portal-vein patency be assessed before hepatic embolization?
- The liver depends on dual inflow. Extensive hepatic arterial embolization in the presence of impaired portal flow substantially increases hepatic necrosis, biliary ischemia and abscess risk.
- Why is renal embolization performed superselectively?
- Renal segmental arteries are end arteries, so every embolized branch produces parenchymal infarction. Superselective treatment controls hemorrhage while preserving the maximum functioning kidney.
- Which embolic should be avoided in a traumatic AVF?
- Particles and uncontrolled liquid embolics should generally be avoided because they can pass through the fistula into the pulmonary or systemic circulation. Detachable coils or a vascular plug provide more controlled occlusion.
- What should you do if CT shows renal extravasation but angiography is negative?
- Perform careful selective angiography of the main and accessory renal arteries and account for vasospasm or intermittent bleeding. If no active lesion is demonstrated in a patient with two kidneys, blind renal embolization is not recommended; continue monitored management and repeat imaging or angiography if bleeding recurs.
- What is the physiological purpose of REBOA?
- It temporarily reduces hemorrhage below the balloon and increases proximal aortic pressure to support coronary and cerebral perfusion. It is only a bridge to immediate definitive hemostasis.
- Define the three REBOA zones.
- Zone 1 is from the left subclavian artery to the celiac artery, Zone 2 from the celiac artery to the lowest renal artery, and Zone 3 from the lowest renal artery to the aortic bifurcation.
- How do you choose between Zone 1 and Zone 3?
- Use Zone 1 for abdominal or uncertain subdiaphragmatic hemorrhage and commonly in traumatic arrest without major chest injury. Use Zone 3 only for isolated pelvic, junctional or proximal lower-extremity hemorrhage after excluding significant abdominal bleeding.
- Why is Zone 2 avoided?
- Balloon inflation in Zone 2 can obstruct or injure the celiac, superior mesenteric or renal arterial origins, causing major visceral ischemia or thrombosis.
- What is partial REBOA?
- Partial REBOA maintains controlled pulsatile flow past the balloon while limiting hemorrhage. Current JTS guidance targets proximal SBP 90–110 mmHg and distal SBP 20–50 mmHg with a compatible device and two-level pressure monitoring.
- What are the major contraindications?
- Major thoracic hemorrhage, cardiac injury or tamponade; known aortic injury across the planned segment; and absence of immediate definitive hemorrhage-control and damage-control-resuscitation capability are key contraindications.
- What does the current evidence say about survival?
- The UK-REBOA randomized trial did not show benefit and suggested possible harm when REBOA was added routinely for exsanguinating trauma. EAST 2025 conditionally recommends against routine use in hypotensive subdiaphragmatic trauma and blunt pelvic fracture, but conditionally favors REBOA over thoracotomy in traumatic arrest when thoracotomy has no other indication.
- Why must balloon deflation be gradual?
- Sudden reperfusion decreases afterload and washes acid, potassium and metabolites into the central circulation, causing hypotension or arrest. Recurrent bleeding may also become apparent, so deflation must be coordinated with resuscitation and definitive hemostasis.
- When is transarterial embolization indicated in upper GI bleeding?
- TAE is principally indicated when nonvariceal upper GI bleeding persists or recurs despite endoscopic therapy, or when endoscopy is impossible or unsuitable. Arterial hemobilia, hemosuccus pancreaticus and visceral pseudoaneurysm may proceed directly to embolization.
- What is empiric GDA embolization?
- It is embolization of the GDA despite absent angiographic extravasation when endoscopy or CTA strongly localizes severe bleeding to a duodenal ulcer or GDA territory. Reliable localization is essential because empiric embolization is not simply treatment of any angiographically negative GI bleed.
- What is the sandwich technique?
- The culprit artery is occluded distal and proximal to the bleeding point, closing both the back door and front door. It is particularly important in the GDA and pancreaticoduodenal arcade because SMA collaterals can maintain hemorrhage after proximal-only embolization.
- Why must the SMA be checked after GDA embolization?
- The inferior pancreaticoduodenal arteries arise from the SMA and communicate with superior pancreaticoduodenal branches of the GDA. SMA angiography can therefore reveal back-door collateral filling or persistent bleeding after celiac-side embolization.
- How does lower GI embolization differ technically from upper GI embolization?
- Lower GI embolization should be ultraselective, preferably at the responsible vasa recta, because colonic collateral supply is less forgiving. Upper GI embolization more often requires occlusion of both sides of the lesion because the stomach and duodenum have extensive collaterals.
- Which embolic is useful in severe coagulopathy?
- NBCA is useful because polymerization and vessel occlusion are less dependent on the patient's coagulation system. It provides rapid hemostasis but demands expertise to prevent reflux, catheter adhesion and nontarget ischemia.
- What is the most feared complication of lower GI embolization?
- Bowel ischemia progressing to infarction or perforation is the principal concern. Risk is reduced by superselective catheterization, limiting the embolized territory and avoiding uncontrolled distal delivery.
- What defines technical success?
- Technical success requires cessation of extravasation or exclusion of the pseudoaneurysm with no relevant collateral refilling. It also requires preservation of uninvolved bowel and visceral arterial perfusion.